Summary Report for FSPSAs Initiated During the Report Period Center: 07
This report shows the total number of units/fees for FSPSAs initiated during the report period.
(i.e., start date of service authorization occurs during the report period). This report does not
represent all FSPSAs that overlap the report period. Note that service authorization periods may
range from 1 to 12 months and may vary in intensity from child to child.
FSPSAs starting between: 01/01/09 and 03/31/09 Date of Report: 05-18-09 Page: 1
Eligibility Filter: Program Patients
Services Cpt Code Number of Number of Total Units Total Cost of Avg Fee
Children Records Authorized Auth Services Per Unit Auth
Service Coordination, Class # 01
TCM -T1017TL TARGETED CASE MANAGEMENT 1 1 10.14 $375.29 $37.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 1 1 10.14 $375.29 $37.00
Screening, Eval, and Assessment, Class # 02
AUD -92626 EVAL OF AUD REHAB STATUS 1 1 1.00 $36.07 $36.07
AUDE -AUDE UNSPECIFIED AUDE SERVICES 9 9 9.00 $540.00 $60.00
AUDE -V5010 ASSESSMENT FOR HEARING AID 2 2 2.00 $93.60 $46.80
AUDE -V5090 DISPENSING FEE PER HEARING AID 2 2 3.00 $358.80 $119.60
BEHV -BEHV BEHAVIORAL ASSESSMENT 1 1 4.43 $553.58 $125.00
BEHV -H0031HO COMP BEHAVIORAL HEALTH ASSESSMENT 1 1 1.00 $125.00 $125.00
EXIT -EXIT TRANSITION ASSESSMENT 1 1 1.00 $50.00 $50.00
IPDEF -IPDEF FOLLOW-UP PSYCH AND DEV EVAL 1 2 2.00 $150.00 $75.00
IPDEF -T1024TS F/U PSYCH AND DEV EVAL BY ITDS 2 2 4.00 $222.00 $55.50
IPDEI -T1024HNUK INITIAL PSYCH AND DEV EVAL BY ITDS 2 2 3.50 $194.25 $55.50
IPDEI -T1024TL INITIAL PSYCH AND DEV EVAL BY EI PR 56 75 106.00 $7950.00 $75.00
MED -99205 OUTPATIENT VISIT, NEW, 60 MINS 1 1 1.00 $72.78 $72.78
MED -MED UNSPECIFIED MED OFFICE VISIT 1 1 1.00 $150.00 $150.00
OCTF -97004 OT EVAL BY LICENSED OT, FOLLOW-UP 4 4 4.00 $194.00 $48.50
OCTH -97003 OT EVAL BY LICENSED OT, INITIAL 58 59 64.25 $3116.01 $48.50
PSTF -97002 EVAL BY LICENSED PT, FOLLOW-UP 7 8 8.00 $388.00 $48.50
PSTH -97001 EVAL BY LICENSED PT, INITIAL 40 41 36.44 $1767.48 $48.50
SPCH -92506 SPEECH EVAL BY LICENSED SLP 178 178 187.43 $9090.32 $48.50
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 302 390 439.05 $25051.88 $57.06
EI Services, Class # 03
ASST -ASST ASSISTIVE TECHNOLOGY 2 2 1.40 $2100.00 $1500.00
AUD -HA_FUP AUDIOLOGY SERVICES 10 10 12.00 $600.00 $50.00
COIFF -COIFF IFSP CONSULT, PROF, FACE TO FACE 10 10 11.90 $595.00 $50.00
COIFP -COIFP IFSP CONSULT, PRO, BY PHONE 3 3 3.13 $78.33 $25.00
CONIF -CONIF CONSULT ITDS, FACE TO FACE 11 11 15.57 $778.34 $50.00
CONIP -CONIP CONSULT, ITDS, PHONE 1 1 1.27 $31.67 $25.00
CONOF -CONOF CONSULT, OT, FACE TO FACE 17 18 22.23 $1111.55 $50.00
CONOP -CONOP CONSULT, OT, PHONE 3 3 2.82 $70.42 $25.00
CONPF -CONPF CONSULT, PT, FACE TO FACE 10 11 8.88 $444.17 $50.00
CONPP -CONPP CONSULT, PT, PHONE 2 2 3.07 $76.67 $25.00
CONSF -CONSF CONSULT, SLP, FACE TO FACE 22 22 22.27 $1113.34 $50.00
CONSP -CONSP CONSULT, SLP, PHONE 8 8 8.53 $213.34 $25.00
ECE -ECE EARLY CHILDHOOD EDUCATION 5 5 68.57 $857.14 $12.50
EIIF -96154 HEALTH AND BEHAVIOR INTERVENTION 2 2 19.86 $992.86 $50.00
EIIF -T1027SC EI INDIVIDUAL SESSION BY EI PROF 286 298 1769.08 $88453.96 $50.00
HERN -T1027SC EI HEARING SERVICES AFTER SHINE 6 6 40.68 $2034.05 $50.00
OCCT -97530 OT SESSION BY LICENSED OT 89 92 673.32 $45705.04 $67.88
OCCT -97530HM OT SESSION BY OT ASST 16 16 105.11 $5709.42 $54.32
PHY -97110 PT SESSION BY LICENSED PT 104 109 735.76 $49943.19 $67.88
PHY -97110HM PT SESSION BY PT ASST 15 16 101.00 $5486.33 $54.32
SCONLY-SCONLY SERVICE COORDINATION ONLY 29 29 27.88 $27.88 $1.00
SENS -FM FM RECEIVER HEARING AID 2 2 2.00 $3300.00 $1650.00
SENS -HA_EIP ONE UNIT UP TO $500 PER AID 2 2 3.00 $1500.00 $500.00
SENS -V5264 EARMOLD 5 5 8.00 $149.76 $18.72
SHIN -T1027SC INITIAL SHINE SERVICES, INDIVIDUAL 1 1 1.00 $50.00 $50.00
SPL -92507 SPL THERAPY SESSION BY LICENSED SLP 278 286 2060.13 $139841.49 $67.88
SPL -92508 GROUP SPL SESSION PER CHILD 56 57 393.61 $5195.59 $13.20
VISN -T1027SC EI VISION SERVICES, INDIVIDUAL 2 2 21.86 $1092.86 $50.00
--------------------------------------------------------------------
Subtotal (Total Children Is Unduplicated) 678 1029 6143.91 $357552.36 $58.20
-----------------------------------------------------------------------------------------------------------------------------
Total 1420 6593.10 $382979.53 $58.09
-----------------------------------------------------------------------------------------------------------------------------
Number of Children (Unduplicated) With at Least One Authorization 714